ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Chambers Brendan John ____________________
5/11/19
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

5102 Golf Road
(P.O. Box or Street Number)

Merced California 95340

_______________________________________________________________________________
(City) (State) (Zip Code)

(209 ) 201-3843 ( 209 )____________________

678-0034 ____________________________
bjmchambers@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

State Department Internship

Skills and/or competencies which qualify you for this position:

French - Intermediate
Advanced Geographical Knowledge
Understanding of foreign policy and international diplomacy

Languages spoken and/or written (other than English):___________________________________

French

Have you ever been convicted, pleaded guilty or no contest to a misdemeanor or felony?
‰ No ‰ Yes If yes, explain:________________________________

Do you possess a valid California Driver’s License?

‰ No ‰ Yes _______________________
Y8778159
(Number)

RECORD OF EDUCATION
Course of
study or Last year Did you Diploma
Name of School City/State major completed graduate? or degree
High School Merced High Merced, CA GE 1 2 3 4 No High
School

College/ 1 2 3 4
Merced College Merced, CA French No N/A
University

Other
1 2 3 4
(Specify)

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Mock Trial - Leading Attorney for the Defense
JSA

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

All Day N/A After 3 After 5 After 3 After 5 All Day

RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment Job Title and Duties Performed Company Name, Address, and Phone Number
From: To:
Title__________________________Last Salary: _____________ _________________________________________________
______ ______
Mo / Yr Mo/Yr
Duties _________________________________________________
Total ____Yrs. ________Mo.
_________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

Supervisor’s Name: _________________________________________________

_____________________________________________________

From: To:
Title__________________________Last Salary: _____________ _________________________________________________
______ ______
Mo/ Yr Mo/Yr Duties: _________________________________________________
Total ____Yrs. ________Mo. _________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

_________________________________________________
Supervisor’s Name:
________________________________________________

From: To:
Title___________________________Last Salary: ____________ _________________________________________________
______ ______
Mo /Yr Mo/Yr Duties: _________________________________________________
Total ____Yrs. ________Mo. _________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

_________________________________________________
Supervisor’s Name:
________________________________________________

REFERENCES: Give the names of three persons not related to you.

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Facundo Sabao 2078 El Portal Drive, Merced, CA, 95348 209-683-8996
Student
________________________________________________________________________________________________________________________________

2. Tom Scott 2251 Santa Fe Drive, Santa Rosa, CA, 95405 707-529-6852
COO, Jackson WG
________________________________________________________________________________________________________________________________

3. Kate Belan 5102 Golf Road, Merced, CA, 95340 209-233-4830

M-Health Clinician
________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

I understand that misrepresentation or omission of facts is cause for dismissal.

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf Revised 7/10